Report of an expert meeting, March 1999, Rochester (Minnesota) USA

II. Tobacco and treatment

The smoking rate among Russian men aged 25-34 is 73%; among women aged 18-34, the rate is 27%, indicating that "tobacco poses a major threat to the health of future generations in Russia", particularly women (McKee et al., 1998).

Some 69% of men in Mumbai, India, use tobacco, with 24% smoking and the rest using smokeless tobacco (betel quid with tobacco); 57% of women in Mumbai use a form of smokeless tobacco, accounting for almost all tobacco use among women (Gupta, 1996).

Men in Ecuador, of whom 45% smoke, are not only more likely than Ecuadorian women to use tobacco, but they also use 60% more tobacco than women (Ockene, Chiriboga, & Zevallos, 1996).

About 58% of Bulgarian men aged 30-39 smoke, while 30% of women in that age group smoke. Tobacco use is more common among those who live in cities, those who are widowed or divorced, and those who do not own homes (Balabanova, Bobak, & McKee, 1998).

Smoking rates among men in Asian and Pacific countries rose from 50% in 1994 to 60% in 1997 (World Health Organization, 1998).

reduce the addictivness of tobacco products by eliminating ingredients that enhance nicotine delivery;

examine ways to reduce the proportion of respirable particles;

explore ventilation in relation to nicotine delivery and pH;

diminish the consumer appeal of the most toxic products;

prevent blockage of cigarette ventilation holes;

reduce the likelihood that cigarettes will cause fires.

the safety of nicotine replacement therapy during pregnancy;

the safety and effectiveness of nicotine replacement therapy when used as an aid to smoking reduction, used over an extended time, and used by children;

effective methods of helping groups of smokers such as schoolchildren and pregnant women cease smoking, and the settings in which they might find help;

the effectiveness of tapering off smoking as an approach to quitting;

the effectiveness of the white paper itself in making an impact on health and health education;

the relationship between tobacco brands and nicotine exposure;

those in diverse populations and underserved groups; effective treatments should be developed for groups for whom treatment has not been available, such as children and adolescents.

1. Tobacco use is widespread

At least one-third of the global adult population, or 1.1 billion people aged 15 years and older, smoked cigarettes in the early 1990s. About 300 million of these smokers were in developed countries, twice as many men as women using tobacco. In less developed countries, about 700 million men and 100 million women were smokers. An estimated 48% of men and 7% of women in developing countries smoked. In industrialized countries, 42% of men and 24% of women smoked, representing a marked increase among women (World Health Organization, 1997). Although tobacco use has decreased in many developed countries, it has increased in most developing countries. Data-gathering studies such as the WHO MONICA project (to MONItor trends and determinants of CArdiovascular disease) have tracked rising smoking rates among European women smokers and among Asian men, two populations of concern (Dobson et al., 1998). Reports from various countries are informative:

Tobacco dependence may be higher among remaining smokers in countries with low smoking prevalence, where smokers of lower levels of dependence have already stopped. Although prevalence rates may be low, those remaining users may have more difficulty quitting (Fagerström et al., 1996).

A long-term tobacco user has a 50% chance of dying prematurely from tobacco-caused disease (Thun et al., 1995). In 1990, tobacco accounted for nearly a quarter of all male deaths and 7% of all female deaths worldwide, including more than 40% of deaths among men in formerly socialist areas. Tobacco-related diseases shortened the lives of affected smokers by an average of 16 years (Peto et al., 1996). A decade ago, tobacco caused some 3 million deaths per year. At present, tobacco causes some 4 million premature deaths yearly, a million of these occurring in developing countries that can least afford the health care burden.

Involuntary exposure to tobacco smoke also poses a significant health risk that may not be evident from tobacco-use statistics alone (e.g. National Health and Medical Research Council, 1997). A recent meta-analysis of epidemiological studies from Japan, the United States, Scotland, England, China, New Zealand, Australia, Italy, and Argentina (He et al., 1999) identified an increased risk for coronary heart disease among those exposed to tobacco smoke. This confirmed findings from a previous meta-analysis (Law, Morris & Wald, 1997) that showed an increased risk of ischaemic heart disease among those exposed through passive smoking. The recent International Consultation on Environmental Tobacco Smoke (ETS) and Child Health (World Health Organization, 1999a) concluded that ETS is "a real and substantial threat to child health, causing death and suffering throughout the world". WHO estimates that that some 700 million children  half the worlds children  are exposed to tobacco smoke.

Tobacco use among children and adolescents is also an epidemic. Most tobacco use starts during childhood and adolescence (Mackay & Crofton, 1996), and worldwide statistics indicate an upward trend in tobacco initiation and use among children. Tobacco is available to children in many countries, even countries with legal prohibitions against tobacco sales to those younger than the age of accountability (e.g. DiFranza et al., 1994; Radecki & Zdunich, 1993). The numerous demographic and psychosocial factors implicated in tobacco use initiation and continued use among children and adolescents deserve continuing, thorough examination (Tyas & Pedersen, 1998).

2. Tobacco products are highly addictive

Tobacco products are carefully designed to undermine efforts to stop using them (e.g. Hurt & Robertson, 1998). Consequently, cessation is not simply a matter of choice for the majority of tobacco users. Instead, it involves a struggle to overcome an addiction (Royal Society of Canada, 1989; US Department of Health and Human Services, 1988). As Stitzer and deWit (1998) explain, the "abuse liability" of nicotine from tobacco products is high.

This means that tobacco users are likely to regularly self-administer nicotine via tobacco, in spite of adverse consequences. Cigarettes are "the most highly abusable nicotine delivery product", Stitzer and deWit note. Benowitz (1998) points out that the nicotine in tobacco achieves many purposes. Nicotine is reinforcing, provides sensory stimulus that enhances satisfaction, affects performance, controls mood and body weight, and may be self-administered to relieve symptoms of some psychiatric disorders, such as depression.

Nicotine inhaled through smoking passes quickly through the arterial blood stream and into the brain, resulting in intense effects in the central nervous system that are behaviourally reinforcing because of their time proximity in relation to inhalation. Nicotine levels drop between cigarettes, allowing the brains nicotinic receptors to resensitize. Additionally, the rapid delivery of nicotine to the brain allows the smoker to regulate the dose of nicotine from a cigarette to achieve specific psychoactive effects.

In addition to these properties and effects, tobacco use also becomes woven into everyday life in physiologically, psychologically, and socially reinforcing ways. Numerous reports from many branches of science detail the interactions between genetics, demographics, personality, psychopathology, and other factors that contribute to the likelihood of a persons becoming and remaining a tobacco user. Particularly compelling is evidence indicating that smokers use the nicotine from smoked tobacco as a form of affect modulation or regulationa fact that becomes evident to many former tobacco users who experience depression during abstinence (American Psychiatric Association, 1996).

Understandably, withdrawal effects, the worst of which last about a month, are a major motivation for continuing to use tobacco. These well-examined effects of abstinence (Hughes & Hatsukami, 1986) pose an obstacle difficult for many smokers to overcome. Dependent smokers typically experience some constellation of the following symptoms during the early days and weeks of tobacco abstinence: cravings and urges to smoke, difficulty concentrating, nervousness, restlessness, irritability, anxiety, cognitive impairment, increased appetite and (eventually) weight gain. The development and refinement of medications have provided a safe way for smokers to stop using tobacco without experiencing the full range and extent of withdrawal symptoms (Hughes et al., 1999)

3. Quitting benefits health

Quitting tobacco use at any point in life provides both immediate and long-term benefits to health. Within a day of ceasing, a smokers carbon monoxide levels approximate those of a nonsmoker. The acute cardiovascular effects of nicotine and tobacco begin to normalize, and heart rate decreases. At all ages, eliminating exposure to tobacco is a form of primary prevention of disease. Even those who have smoked for years and who are experiencing the health consequences of tobacco use can benefit from cessation. The risk of recurrent heart attack diminishes among newly abstinent patients with heart disease.

Quitting smoking reduces risks and increases exercise tolerance in those who already have peripheral artery occlusive disease. The clinical course of patients with gastric and duodenal ulcers improves when they stop using tobacco. Smokers with cancer can reduce their risk of additional cancers if they quit. Quitting smoking also reduces the risk of respiratory infections such as chronic obstructive lung disease. Women who stop smoking before pregnancy give birth to babies with the same birth weight as babies born to mothers who never smoked (see US Department of Health and Human Services, 1990.)

Conversely, no amount of tobacco use is safe. The use of any tobacco product, even one bearing claims of reduced risk, involves some hazard to health (US US Department of Health and Human Services, 1988; American Council on Science and Health, 1997). Risk varies from product to product: cigarettes carry a higher hazard for cardiovascular disease than smokeless tobacco, while fermented smokeless tobacco is implicated in oral cancers. Those who attempt to minimize their tobacco use to reduce health risk are often surprised to find that they are unable to smoke only a few cigarettes a day or use only a small amount of snuff. Because few tobacco users are able to avoid becoming addicted to nicotine, abstinence from tobacco products and freedom from exposure to second hand smoke are necessary for maximizing health and minimizing risk (see Whelan, 1997).

Effective treatment for tobacco dependence can significantly improve overall public health within only a few years. No other intervention or prevention mechanism has the potential to reduce tobacco-related disease and death as quickly as treatment for tobacco dependence (see Fig. 1; Henningfield & Slade, 1998). A combination of treatment and other tobacco control strategies, notably prevention, can reduce rates of death and disease dramatically. Over the next 30 years, the extent of tobacco-caused death and disease will be determined largely by the numbers of existing smokers who are able to become abstinence or greatly reduce their exposure to tobacco.

4. Current treatment methods work

Tobacco users who attempt to quit on their own tend to remain abstinent only a few days at most. Medications and behavioural therapies are both effective, and each approach can be effective when used alone. The use of pharmacotherapy can double short-term success rates compared to placebos (Fiore et al., 1996). Controlled trials indicate that medications can work independently of behavioural or psychosocial therapy, or of other interventions (Hughes et al., 1999). Meta-analyses of hundreds of controlled scientific studies have created a road map for providing successful tobacco dependence treatment, even though the range of what constitutes treatment is wide. Treatment could involve attending a stop-smoking group at a local health clinic, or the use of over-the-counter medication. It could also involve a physician, dentist, psychologist, nurse, or pharmacist enquiring about tobacco use status and offering to help the user quit. Effective treatment can involve a variety of methods, such as a combination of behavioural treatment and pharmacotherapy (e.g. nicotine replacement, non-nicotine medication such as bupropion, or both). Treatments that are the most effective deal with the reality that tobacco dependence is a chronic disorder and the fact that dependent users are prone to relapse. A single treatment intervention may have only a minor impact, but extended efforts, information, and contact can result in long-term benefits.

An increasing number of governments have undertaken the task of outlining guidelines for effective treatment. Two leading efforts in this regard were guidelines issued in 1996 by the US Agency for Health Care Policy and Research (AHCPR), Smoking cessation (Fiore et al., 1996), and Englands "Smoking cessation guidelines for health professionals" published in the journal Thorax (Raw, McNeill, & West, 1998). This document was published in parallel with guidance on the cost-effectiveness of treatment. Additionally, the American Psychiatric Association (1996) published guidelines for treatment of tobacco dependence in psychiatric patients and tobacco users otherwise unable to quit. All three of these sets of guidelines are "evidence-based", in that their recommendations are based on statistical findings of treatment efficacy, and on published evidence and expert opinion.

The recommendations promoted in the various guidelines are similar. The treatments endorsed generally include brief advice, behavioural therapy, nicotine replacement, and bupropion. Primary care providers and their associates are asked to assess smoking status of patients at every opportunity, to advise tobacco users to stop, to assist them in doing so, to offer follow-up, and to refer the patient to a specialist service if necessary. Caregiver teams should recommend pharmacotherapy for all smokers who want to stop, and should provide accurate information and advice about medications. These expectations extend to all other health professionals as well. Psychologists (Wetter et al., 1998) and pharmacists (e.g., Sinclair et al., 1998; Tomasello, 1997) in particular have been given guidance in implementing recommendations such as those provided by the AHCPR. By the time the Thorax guidelines were published, the document had been endorsed by numerous governmental and professional groups, including nurses, physicians, midwives, and pharmacists.

Treatment for tobacco dependence has proved to be a cost-effective means of helping to control the overall tobacco use epidemic, as explained in the companion document to Englands treatment guidelines (Parrott et al., 1998). The authors outline potential health gains and costs of implementing interventions across the countrys population. In an examination of life-years saved as a result of treatment, tobacco dependence treatment compares favourably with most health care procedures, and is far less expensive than the median societal cost of many life-preserving medical interventions.